Provider Demographics
NPI:1326187352
Name:FRALEY, MATTHEW ALAN (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALAN
Last Name:FRALEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 GRAHAM RD STE C-2310
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-8023
Mailing Address - Country:US
Mailing Address - Phone:618-228-4215
Mailing Address - Fax:
Practice Address - Street 1:1225 GRAHAM RD STE C-2310
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-8023
Practice Address - Country:US
Practice Address - Phone:618-228-4215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-123183207RC0000X
MO2004021586207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.123183OtherIL LICENSE
MO2004021586OtherMO LICENSE